Tops, Middles and Bottoms: Why We Misunderstand Each Other in the NHS

Why do good people in the NHS so often misunderstand one another? Barry Oshry's work on Tops, Middles and Bottoms offers a powerful lens for understanding organisational tension, leadership and wellbeing.

In his work on organisational systems, Barry Oshry describes life in organisations through three lenses: Tops, Middles and Bottoms.

Oshry's work explored why well-intentioned people in organisations so often misunderstand one another. He argued that the problem frequently lies not in the people themselves, but in the conditions created by the roles they occupy. Change the conditions and people often behave differently.

At first glance, the model appears to be a description of hierarchy or status. In reality, it describes the very different realities people inhabit within organisations. Those realities shape what they see, how they behave and what they believe needs to happen next.

• “Tops” carry accountability for the whole system. They often experience complexity, uncertainty and the weight of organisational responsibility.
• “Middles” are pulled in multiple directions, translating strategy into reality whilst balancing competing expectations from above and below.
• “Bottoms” deliver the work of the organisation. They experience the day-to-day realities of delivery and can often feel at the effect of decisions made elsewhere.

The longer I have worked in the NHS, the more I have come to appreciate how accurately this captures organisational life in the NHS.

Over the course of my career, I have inhabited all three worlds. As a consultant neurologist, I experienced life primarily from the ‘Bottom of the system’, using the terminology of Oshry, focused on caring for patients whilst often feeling at the effect of decisions made elsewhere.

As a Clinical Lead and later Clinical Director, I experienced the tensions of the Middle, trying to reconcile and translate organisational priorities into the realities of delivering care. And then, as a Medical Director, I experienced the pressures of the Top, carrying accountability for organisational performance, quality, workforce and finance. Today, in my role as Associate Medical Director for Senior Doctor Wellbeing, I have the privilege of moving between all three perspectives, listening to doctors, clinical leaders and executives describe the challenges they face.

What strikes me is how often each group misunderstands the others.

Frontline clinicians can view 'management' as disconnected from the realities of patient care. Clinical leaders can feel trapped between organisational expectations and the needs of their teams. Executives can feel overwhelmed by the scale and complexity of the problems they are expected to solve.

Yet most people are dedicated, care deeply about patients and are working hard to do the right thing.

The challenge is not that one group is right and another is wrong. The challenge is that each group is responding rationally to the conditions they experience.

Each level experiences a different balance between responsibility, control and autonomy.

• Those providing care often carry immense responsibility in a high stakes, high stress environment but often feel little control over staffing, targets, budgets or resources.
• Those in the Middle are accountable both upwards and downwards, frequently carrying responsibility that exceeds their authority.
• Those at the Top may appear powerful, yet their autonomy is constrained by regulators, finances, workforce shortages and political priorities.

The people clinicians often refer to as 'management' are rarely a separate group. In many organisations, there is a subtle process of othering, where colleagues who move into leadership roles are seen as having crossed a divide. Yet these individuals are usually the same doctors, nurses and managers who came into healthcare for the same reasons as everyone else. What changes is not their values but the context in which they work. Their responsibilities, pressures and accountabilities are different, and these shape what they notice, worry about and prioritise.

Oshry argued that people become 'context blind'. We assume that others see the world as we do and judge them when they behave differently. In reality, they are responding rationally to the conditions they experience.

This connects closely with a concept from Stoic philosophy: the dichotomy of control.

Much of our frustration arises when we focus our attention on things that sit outside our control. In healthcare there is no shortage of such things: national policy, regulatory requirements, financial constraints, organisational decisions and the actions of other people.

That does not mean we become passive or stop trying to improve things. The Stoics did not advocate withdrawal from the world. Quite the opposite. They encouraged people to focus their energy on actions that are within their control whilst accepting that outcomes are not.

We can support colleagues, improve processes, challenge constructively, build relationships and lead with compassion. But whether those actions achieve the results we hope for is never entirely ours to determine.

In my wellbeing role, I often hear doctors describe feeling exhausted by problems they cannot solve. Sometimes the most helpful conversation is not about wellbeing interventions, coping strategies or personal development. It is about helping people recognise the gap between what they feel responsible for and what is actually within their control.

The paradox is that when we stop trying to control what cannot be controlled and focus instead on how we act, the choices we make and the values we bring to our work, we often have the greatest impact.

Perhaps that is the real lesson from Oshry's work. The NHS will always contain tensions between Tops, Middles and Bottoms. The goal is not to eliminate those tensions or decide which perspective is correct. The goal is to understand that different parts of the system create different realities.

Having worked at all three levels, I have become less interested in deciding who is right and more interested in understanding the conditions under which people are working. When we do that, judgement often gives way to curiosity, frustration can give way to compassion, and we create the possibility of working together more effectively.

In a healthcare system under immense pressure, understanding one another's realities may be one of the most important shifts we can make.